Healthcare Provider Details

I. General information

NPI: 1861396707
Provider Name (Legal Business Name): COUNTRYSIDE CAPITAL ESTATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 E GOLF LINKS RD
TUCSON AZ
85713-5317
US

IV. Provider business mailing address

87 N BUESCHING RD APT 427
LAKE ZURICH IL
60047-6723
US

V. Phone/Fax

Practice location:
  • Phone: 520-822-4208
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL

VIII. Authorized Official

Name: DERICK KAMBOBE
Title or Position: MANAGER
Credential:
Phone: 224-223-3089